1598093767 NPI number — ILLINOIS MENTOR

Table of content: (NPI 1598093767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598093767 NPI number — ILLINOIS MENTOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS MENTOR
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MARION SITE 014015
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598093767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4503 W DEYOUNG ST
Provider Second Line Business Mailing Address:
SUITE 203C
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62959-7654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-997-9470
Provider Business Mailing Address Fax Number:
618-997-9478

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4503 W DEYOUNG ST
Provider Second Line Business Practice Location Address:
SUITE 203C
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62959-7654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-997-9470
Provider Business Practice Location Address Fax Number:
618-997-9478
Provider Enumeration Date:
11/30/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NGWA
Authorized Official First Name:
VIVIANE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
708-679-9137

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 320600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)